Engaging with culturally and linguistically diverse communities to reduce the impact of depression and anxiety: a narrative review

Culturally and linguistically diverse (CALD) communities in Australia face significant challenges in terms of reducing barriers to information and support for depression and anxiety. Increased stigma surrounding mental ill‐health in some cultures and related concerns about trust and confidentiality all impact upon timely access to information, services and support for consumers and carers from CALD backgrounds. For health services, there is a need to understand how to better engage CALD communities in mental healthcare. The objective of this narrative review was to identify examples of evidence‐based, best practice for what works effectively for engaging with CALD communities to reduce the impact of depression and anxiety. In January 2014, we searched Academic Search Premier, CINAHL, Health‐Source Consumer Edition, PsycARTICLES, PsycINFO (all databases within the EbscoHost platform) and PubMed for peer‐reviewed articles published between 1994 and 2014. The search revealed a total of 706 records contained within the EbscoHost platform and 689 records in PubMed; 15 matched the inclusion criteria. Six key themes were identified: (i) setting the scene for engagement; (ii) cultural values and preferences; (iii) language considerations; (iv) ‘engagers’ in the therapeutic process; (v) opening out engagement to include others; and (vi) engaging through the use of technology and alternative mediums. The literature obtained provides a small body of evidence regarding approaches to engaging CALD communities, with findings highlighting the importance of processes which are tailored to the CALD community of interest and which take into account different cultural explanatory models of mental ill‐health. Review findings are also discussed within the framework of intersectionality, in which broader structural inequalities and power imbalances – in areas such as gender and social class – collectively impact on help‐seeking and mental health outcomes. This review supports further enquiry into how such societal issues influence engagement – and disengagement – in mental health services for CALD communities.     

“Football is pure enjoyment”: An exploration of the behaviour change processes which facilitate engagement in football for people with mental health problems

IntroductionPhysical activity is known to be beneficial for people with mental health problems, although engagement is low. Football, provided by professional football club community trusts could aid engagement in physical activity, however little is known about the behaviour change processes which engage individuals in this type of PA. One factor which is often overlooked is affect and exploring this could help identify the behaviour change processes, which engage individuals in a professional football club-led mental health intervention. The aim of this study was to explore the experiences of individuals attending football provided by a professional club community trust to further our understanding of the behaviour change processes involved in facilitating engagement in this provision.MethodSemi-structured interviews were conducted with twelve men who played football provided by a professional football club trust. A range of mental health problems were reported and the participants were aged between 19 and 46. Template analysis was conducted, implementing some of the concepts from the Affective – Reflective Theory (ART).ResultsThe results highlighted that both affective and reflective processes of ART were evident in engaging individuals in football. Pleasurable experiences were enabled through the physical and social characteristics of football. Self-control strategies emerged which help to action engagement. The professional football club trust provided coaching knowledge and skills, team organisation and resources and feelings of belonging and responsibility.ConclusionApplication of ART to the understanding of football experiences has provided a novel exploration of the processes involved in engaging individuals in football. This has important implications for intervention design; the focus should be on providing pleasurable experiences and fostering appropriate self-control strategies.     

Community treatment orders and care planning: How is engagement and decision‐making enacted?

BackgroundIn many jurisdictions worldwide, individuals with a mental illness may be forced to receive care and treatment in the community. In Australia, legislation states that such care should be driven by a care plan that is recovery‐focussed. Key components in the care planning process include engagement and decision‐making about a person''s support needs and care options, with trust being an essential component of care planning relationships.ObjectiveThis study examines how these components were enacted during service care contacts for individuals on community treatment orders.MethodsThe study was located at two community mental health teams in South Australia. Ethnographic observations of care planning discussions between consumers, their carers and clinicians, and interviews with individuals from these groups, were conducted over 18 months. Carspecken''s critical ethnography provided a rigorous means for examining the data to identify underlying cultural themes that were informing day‐to‐day care interactions.ResultsCare planning was not occurring as it was intended, with service culture and structures impeding the development of trusting relationships. Clinicians striving to work collaboratively with consumers had to navigate a service bias and culture that emphasized a hierarchy of ‘knowing’, with consumers assumed to have less knowledge than clinicians.ConclusionsServices and clinicians can challenge prejudicial ethical injustice and counter this through testimonial justice and implementation of tools and approaches that support genuine shared decision‐making.Patient or Public ContributionThis study included individuals with lived experience of mental illness, their carers and clinicians as participants and researchers.     

An Evaluation of Overcoming Barriers to Engage Consumers in the Use of Health Care Information Technology

The purpose of this review is to determine why consumers may not be adopting or engaging in the use of health information technology to successfully improve or maintain their health status. A literature search was completed to find articles related to consumer engagement in the use of health information technology. The literature found was then categorized based on a patient engagement framework defined by the National eHealth Collaborative. The barriers to engagement, issues with types of technology, and problems in study methodology were then synthesized for understanding consumer engagement. The results of the review showed the major barriers related to engaging consumers in the use of health information technology, including privacy, education, cost, literacy, accuracy of information, trust, meeting consumer needs, measures, integration, and policy. The most prevalent of these issues is that health information technology is often not designed with accurate and detailed user requirements in mind. Issues of the methodologies used to show how consumer health information technology is consumed relate to studies that are not aligned with the original purpose of the experiment. Additional work and research is needed to ensure that the design of consumer health information technology meets the consumer’s needs. Improved designs and methods of achieving these designs will create technology that consumers find appealing to use in order to better manage their health. If consumers find value in the technology, they will be more likely to engage and adopt it for additional use.     

Codesigned recommendations for increasing engagement in structured physical activity for people with serious mental health problems in Australia

People with mental health problems are at higher risk of physical health comorbidities and early mortality. A key risk factor for poor health outcomes is a lack of regular physical activity. Mental health services have typically responded by focusing on screening and promoting lifestyle programmes within secondary care mental health settings. The aim of this study was to better understand the barriers and enablers for Australian mental health consumers to participate in physical activity or exercise programmes from the perspectives of consumers and exercise practitioners. Interviews with 15 consumers experiencing serious mental health problems and five exercise practitioners were undertaken, followed by two focus groups (involving eight consumers and two exercise practitioners) to gain consensus on themes from the interviews, and codesign a set of recommendations for services to support and increase the engagement of mental health consumers in regular community‐based exercise. Barriers that impacted on engagement in physical activity included: lack of social support, insufficient knowledge and information, difficulties with work/life balance, impact of physical and mental health issues, fear and lack of confidence, and financial cost. Enablers or motivators assisting engagement in community‐based physical activity programmes included: social support, access to person‐centred individualised exercise options, connection and a sense of belonging, and access to information and education. Recommendations and a checklist were developed to assist services to increase the involvement of mental health consumers in community‐based exercise and to ensure that exercise practitioners and their employing organisations are adequately equipped to work with this population.     

Engaging communities to improve mental health in African and African Caribbean groups: a qualitative study evaluating the role of community well‐being champions

Over the last decade, Britain has undergone reforms to promote engagement in local structures of governance. These reforms have encouraged the promotion of active citizenship and have been central to the government's public service modernisation agenda. This article presents the findings from a study evaluating a pilot outreach intervention which adopted a community engagement model to address the mental health needs of African and African Caribbean groups, which entailed a partnership between faith‐based organisations, local public services and community organisations to co‐produce the pilot project. Lay people were trained to raise awareness about mental health among these communities in South London. Between 2012 and 2013, a qualitative participatory approach was used to evaluate the pilot project, which enabled a researcher to take part in the engagement phase of the pilot project, and the project co‐ordinators to be involved in the research process. Semi‐structured, one‐to‐one interviews were carried out with 13 community and well‐being champions (CWBCs) recruited from African and African Caribbean communities (seven male and six female). This study examines the impact of the relationship between the intervention and community through the participants’ engagement in the pilot outreach project and the action undertaken as champions. We found that although CWBCs used circles of influence to share ideas about mental health and well‐being and to encourage change, they encountered resistance on the part of the people they engaged with, which resulted from a lack of knowledge about mental health, taboos and ascribed stigma. We argue that CWBCs acted as healthy examples to communicate mental health knowledge to those approached, but that they needed to be equipped with bespoke communication skills to be able to talk about such sensitive issues as mental health.     

Strengthening community mental health competence—A realist informed case study from Dehradun,North India

Few accounts exist of programmes in low‐ and middle‐income countries seeking to strengthen community knowledge and skills in mental health. This case study uses a realist lens to explore how a mental health project in a context with few mental health services, strengthened community mental health competence by increasing community knowledge, creating safer social spaces and engaging partnerships for action. We used predominantly qualitative methods to explore relationships between context, interventions, mechanisms and outcomes in the “natural setting” of a community‐based mental health project in Dehradun district, Uttarakhand, North India. Qualitative data came from focus group discussions, participant observation and document reviews of community teams' monthly reports on changes in behaviour, attitudes and relationships among stakeholder groups. Data analysis initially involved thematic analysis of three domains: knowledge, safe social spaces and partnerships for action. By exploring patterns within the identified themes for each domain, we were able to infer the mechanisms and contextual elements contributing to observed outcomes. Community knowledge was effectively increased by allowing communities to absorb new understanding into pre‐existing social and cultural constructs. Non‐hierarchical informal community conversations allowed “organic” integration of unfamiliar biomedical knowledge into local explanatory frameworks. People with psycho‐social disability and caregivers found increased social support and inclusion by participating in groups. Building skills in respectful communication through role plays and reflexive discussion increased the receptivity of social environments to people with psycho‐social disabilities participation, thereby creating safe social spaces. Facilitating social networks through groups increases women's capacity for collective action to promote mental health. In summary, locally appropriate methods contribute most to learning, stigma reduction and help‐seeking. The complex social change progress was patchy and often slow. This study demonstrates a participatory, iterative, reflexive project design which is generating evidence indicating substantial improvements in community mental health competence.     

Multi-level rural community engagement in health

Community participation in health is consistent with notions of democracy. A systems perspective of engagement can see consumers engaged to legitimise government agendas. Often community participation is via consultation instead of partnership or delegation. A community development approach to engagement can empower communities to take responsibility for their own health care. Understanding rural place facilitates alignment between health programs and community, assists in incorporating community resources into health care and provides information about health needs. Rural communities, health services and other community organisations need skills in working together to develop effective partnerships that transfer some power from health systems. Rural engagement with national/state agendas is a challenge. Community engagement takes time and resources, but can be expected to lead to better health outcomes for rural residents.     

Community and facility-level engagement in planning and budgeting for the government health sector--a district perspective from Kenya

Health systems reform processes have increasingly recognized the essential contribution of communities to the success of health programs and development activities in general. Here we examine the experience from Kilifi district in Kenya of implementing annual health sector planning guidelines that included community participation in problem identification, priority setting, and planning. We describe challenges in the implementation of national planning guidelines, how these were met, and how they influenced final plans and budgets. The broad-based community engagement envisaged in the guidelines did not take place due to the delay in roll out of the Ministry of Health-trained community health workers. Instead, community engagement was conducted through facility management committees, though in a minority of facilities, even such committees were not involved. Some overlap was found in the priorities highlighted by facility staff, committee members and national indicators, but there were also many additional issues raised by committee members and not by other groups. The engagement of the community through committees influenced target and priority setting, but the emphasis on national health indicators left many local priorities unaddressed by the final work plans. Moreover, it appears that the final impact on budgets allocated at district and facility level was limited. The experience in Kilifi highlights the feasibility of engaging the community in the health planning process, and the challenges of ensuring that this engagement feeds into consolidated plans and future implementation.     

Domestic violence: a comparative survey of levels of detection, knowledge, and attitudes in healthcare workers

The objective of this study was to compare the knowledge, attitudes, responses and levels of detection of domestic violence among a variety of healthcare workers in different specialities.Self-administered questionnaires were sent to community and hospital based healthcare workers in Oxfordshire working in primary care, obstetrics and gynaecology, mental health and accident and emergency. These comprised all principal general practitioners and general practitioner registrars, 50% of practice/district nurses and health visitors in each practice, and all healthcare workers in obstetrics and gynaecology, community mental health teams and accident and emergency in one trust.The amount of domestic violence detected in different healthcare settings was far less than indicated by anonymous surveys and crime figures. Knowledge about many of the issues surrounding domestic violence was inconsistent and there were fundamental deficiencies. The attitudes of healthcare workers to domestic violence were generally sympathetic and supportive. Women, nurses and community mental health workers reported significantly better knowledge and more positive attitudes than other respondents. Gender, role and speciality were independently associated with more positive attitudes and the latter two were independently associated with good knowledge. The response that healthcare workers make when they uncover domestic violence is confused and often inappropriate.In conclusion, most healthcare workers accept that domestic violence is a healthcare issue but lack fundamental knowledge about the issues surrounding domestic violence itself and appropriate agencies that can offer help. They also lack skills in identifying and discussing this issue with patients/clients. A large, unfulfilled training need has been identified.     

Facilitating neurorehabilitation through principles of engagement

A primary goal of neurorehabilitation is to guide recovery of functional skills after injury through evidence-based interventions that operate to manipulate the sensorimotor environment of the client. While choice of intervention is an important decision for clinicians, we contend it is only one part of producing optimal activity-dependent neuroplastic changes. A key variable in the rehabilitation equation is engagement. Applying principles of engagement may yield greater neuroplastic changes and functional outcomes for clients. We review the principles of neuroplasticity and engagement and their potential linkage through concepts of attention and motivation and strategies such as mental practice and enriched environments. Clinical applications and challenges for enhancing engagement during rehabilitation are presented. Engagement strategies, such as building trust and rapport, motivational interviewing, enhancing the client education process, and interventions that empower clients, are reviewed. Well-controlled research is needed to test our theoretical framework and suggested outcomes. Clinicians may enhance engagement by investing time and energy in the growth and development of the therapeutic relationship with clients, as this is paramount to maintaining clients' investment in continuing therapy and also may act as a driver of neuroplastic changes.     

Building Community Disaster Resilience: Perspectives From a Large Urban County Department of Public Health

An emerging approach to public health emergency preparedness and response, community resilience encompasses individual preparedness as well as establishing a supportive social context in communities to withstand and recover from disasters. We examine why building community resilience has become a key component of national policy across multiple federal agencies and discuss the core principles embodied in community resilience theory—specifically, the focus on incorporating equity and social justice considerations in preparedness planning and response. We also examine the challenges of integrating community resilience with traditional public health practices and the importance of developing metrics for evaluation and strategic planning purposes. Using the example of the Los Angeles County Community Disaster Resilience Project, we discuss our experience and perspective from a large urban county to better understand how to implement a community resilience framework in public health practice.BUILDING COMMUNITY resilience to disasters—the ability to mitigate and rebound quickly—has received increased attention in the relatively new field of public health emergency preparedness and is now a central focus and a required activity for all public health departments that are recipients of Centers for Disease Control and Prevention (CDC) Public Health Emergency Preparedness (PHEP) grants.1 Critical lessons from Hurricane Katrina in 2005, the H1N1 pandemic of 2009, and, most recently, Hurricane Sandy continue to demonstrate that underlying issues of lack of trust and the absence of sustainable engagement with community-based organizations, faith-based organizations, and other neighborhood-level organizations create significant disparities in population health outcomes following emergencies and disasters. This situation hampers public health interventions in both everyday public health work and emergency response.2,3 As a theory and approach, community resilience provides a framework that embraces principles of equity and social justice with a focus on developing the core capacities of populations both to mitigate disasters and to rebound from them.4 The challenge is to clearly and operationally define community resilience, develop principles and practices that expand and enhance current community-based activities, and, through these changes, better align and integrate traditional public health and public health emergency preparedness.Although the term community resilience is relatively new to emergency preparedness, the emerging operational frameworks embrace many of the core components of effective community-based public health practice and, in many ways, represent a reframing of long-standing approaches to improve community well-being that have not been incorporated in preparedness programmatic activities.5We review the origins of the community resilience framework in the multidisciplinary research on individual resilience and assess how community resilience and related frameworks are shaping federal policies in all agencies involved in disaster and public health emergency response. We describe how the community resilience framework augments public health preparedness and reinforces longer-standing public health approaches to improving community health by examining a multiyear process developed by the Los Angeles County Department of Public Health (LACDPH) to implement this approach. The strategy consists of operationalizing community resilience through the following steps:

• Improving the community engagement skills of health department staff and building sustainable community engagement processes;
• Developing a resilience tool kit that can be used by community organizations to build coalitions and coordinated neighborhood strategies to increase community preparedness and specific mitigation skills; and
• Identifying metrics so that systematic interventions that can improve the abilities of communities to promote resilience and mitigate disaster impacts can be measured and evaluated.

     

Engaging Caregivers in the Treatment of Youth with Complex Developmental and Mental Health Needs

Caregivers of youth with coexisting cognitive and mental health problems face difficult treatment decisions for their child and have unique challenges engaging in shared decision-making. Many stakeholders can influence care management decisions, and the child’s cognitive impairment often prohibits their inclusion in the shared decision-making process. In-depth interviews and focus groups with 37 caregivers elicited their experiences with care management related to their child’s educational, mental health, and other care needs. Four themes that describe the process of engagement were awareness, activation, formulating a strategy, and action. Findings show psychoeducation, and peer-to-peer support could enhance caregivers’ awareness of the condition and encourage activation, which would help in navigating complex service sectors. Coordinated services could enhance capabilities for formulating a strategy jointly with multiple providers and stakeholders. Ultimately, this would contribute to shared decision-making around a common treatment goal that hopefully leads to better quality of care in the least restrictive setting.     

Managing animal disease risk in Australia: the impact of climate change

Climate change is one of a number of factors that are likely to affect the future of Australian agriculture, animal production and animal health, particularly when associated with other factors such as environmental degradation, intensive animal production, an increasing human population, and expanding urbanisation. Notwithstanding the harshness and variability of Australia's climate, significant livestock industries have been developed, with the majority of products from such industries exported throughout the world. A critical factor in achieving market access has been an enviable animal health status, which is underpinned by first class animal health services with a strong legislative basis, well-trained staff, engagement of industry, effective surveillance, good scientific and laboratory support, effective emergency management procedures, a sound quarantine system, and strong political support. However, enhancements still need to be made to Australia's animal health system, for example: re-defining the science-policy interface; refining foresight, risk analysis, surveillance, diagnostics, and emergency management; improving approaches to education, training, technology transfer, communications and awareness; and engaging more with the international community in areas such as capacity building, the development of veterinary services, and disease response systems. A 'one health' approach will be adopted to bring together skills in the fields of animal, public, wildlife and environmental health. These initiatives, if managed correctly, will minimise the risks resulting from global warming and other factors predisposing to disease.     

Community Engagement in Youth Violence Prevention: Crafting Methods to Context

The purpose of the Youth Violence Prevention Centers (YVPC) Program at the Centers for Disease Control and Prevention is to reduce youth violence in defined high-risk communities through the implementation and evaluation of comprehensive, evidence based prevention strategies. Within this common framework, each YVPC varies in its structure and methods, however all engage communities in multiple ways. We explore aspects of community engagement employed by three centers that operate in very different contexts: a rural county in North Carolina; a suburban area of Denver, Colorado; and an urban setting in Flint, Michigan. While previous research has addressed theories supporting community involvement in youth violence prevention, there has been less attention to the implementation challenges of achieving and sustaining participation. In three case examples, we describe the foci and methods for community engagement in diverse YVPC sites and detail the barriers and facilitating factors that have influenced implementation. Just as intervention programs may need to be adapted in order to meet the needs of specific populations, methods of community engagement must be tailored to the context in which they occur. We discuss case examples of community engagement in areas with varying geographies, histories, and racial and ethnic compositions. Each setting presents distinct challenges and opportunities for conducting collaborative violence prevention initiatives and for adapting engagement methods to diverse communities. Although approaches may vary depending upon local contexts, there are certain principles that appear to be common across cultures and geography: trust, transparency, communication, commitment. We also discuss the importance of flexibility in community engagement efforts.     

Emergency psychiatric assessments: do outcomes match priorities?

The targeting of scarce mental health resources is currently organised around three broad areas: treating severe mental illness; reducing suicide; and obviating risk to the wider community. High priority clients are those who present with either psychotic symptoms, or who are perceived to be high risk to self or others. This study examined records of emergency assessments at a mental health trust in the south-east of England over a three-month period (n = 336) to see whether clients with these characteristics are more likely than others to be offered hospital admission or treatment. It was found that clients presenting with psychosis are much more likely to be offered admission than those assessed as non-psychotic, that those assessed as a suicide risk are also significantly more likely to be offered admission, and that those assessed as presenting a risk to the public at large are no more likely to be admitted than those presenting no risk. This investigation indicates that the emergency service of the trust studied is addressing the first two target areas, but may be underperforming in the third.     

Staff perspectives on the barriers and facilitators to exercise implementation in inpatient mental health services: A qualitative study

Exercise has multiple benefits for the physical and mental health of people with severe mental health problems (SMI). However, people with SMI engage in significantly less exercise than the general population and there is an evidence-practice gap regarding the implementation of exercise in clinical services. Mental health staff in inpatient services are well placed to support people with SMI to exercise, yet little is known about staff perspectives on exercise facilitation in inpatient care. This study aimed to explore staff views on role for exercise for people with SMI and the barriers and facilitators to exercise implementation in inpatient services. Qualitative semi-structured interviews were conducted with 25 clinicians working in inpatient mental health settings. Interview topics included the role for exercise in inpatient services, staff roles in relation to exercise, the barriers and facilitators to patients’ engagement in exercise, and promotion of exercise. Interview data were analysed using Thematic Analysis. Four key themes were developed: (i) perceived patient factors, (ii) exercise in the context of relationships, (iii) the ward context, and (iv) the therapeutic role for exercise. Clinicians readily recognised the benefits of service users engaging in exercise, though identified a number of individual, systemic, and organisational barriers to exercise implementation in inpatient services. Organisational prioritisation of exercise and support for staff to develop their skills and confidence in exercise facilitation is required. Enhancing the legitimacy of exercise as a multi-beneficial intervention for people with SMI is essential. Further recommendations for services based on the study findings are provided.     

Multi‐Level Determinants of Mothers' Engagement in Home Visitation Services*

A two‐level hierarchical linear model was used to investigate the impact of poor community health and maternal isolation on mothers' active engagement in a home‐visiting family support program. Data came from 4,057 mothers with firstborn infants who enrolled in the Oregon Healthy Start (OHS) home‐visiting program from 1995 through 1998. At the time of this study OHS operated in 15 Oregon counties. Results showed that if the mother was living in a county that displayed poor community health, or if the mother was isolated from immediate family and friendship networks, the likelihood of actively engaging in home visits was significantly reduced. Implications for programming and study limitations are discussed.     

Interorganisational cooperation and its effects on community rehabilitation for people with severe mental disorders in Beijing,China: A case study

A national comprehensive management pilot project for mental health has been implemented in China to provide integrated care for people with severe mental disorders through strengthened cooperation among government organisations and between government and other relevant social organisations. The promotion of community rehabilitation has been included as a key part of this pilot program. The present study took the AD district of Beijing as a case study to examine interorganisational cooperation and its effects on community rehabilitation in a real-world setting. Interviews were conducted with 14 frontline workers, including 7 mental health workers from community health centres and 3 staff and 4 social workers working in rehabilitation centres. Five officials from relevant health and social welfare departments and a social work organisation were also interviewed. Experiences in Beijing revealed that interorganisational cooperation helped to build a multiagency workforce furnished with basic mental health knowledge at the community level, which rendered it possible for frontline workers to provide fundamental follow-up services, pilot the case management model of service provision and increase the provision of psychosocial rehabilitation services within the poorly resourced context of Chinese mental healthcare. Moreover, the engagement of social organisations provided bottom-up pressure to innovate through the active bringing forward of new ideas concerning cooperation and service delivery. However, differences in professional authority and commitment were observed. Health department officials and health professionals seemed to exercise a dominant role as compared to social welfare department officials and social workers. Future policy making should motivate social welfare department officials to improve social care for people with severe mental disorders. Social workers require training to improve their knowledge of mental health matters, and social organisations need greater latitude to strengthen their influence over the development of community rehabilitation services for people with severe mental disorders.